Korean J Radiol 6(4), December 2005 235

Percutaneous Treatment of ExtrahepaticBile Duct Stones Assisted by BalloonSphincteroplasty and Occlusion Balloon

Objective: To describe the technical feasibility and usefulness of extrahepaticbiliary stone removal by balloon sphincteroplasty and occlusion balloon pushing.

Materials and Methods: Fifteen patients with extrahepatic bile duct stoneswere included in this study. Endoscopic stone removal was not successful in 13patients, and two patients refused the procedure due to endoscopy phobia. Atfirst, all patients underwent percutaneous transhepatic biliary drainage (PTBD). Afew days later, through the PTBD route, balloon assisted dilatation for commonbile duct (CBD) sphincter was performed, and then the stones were pushed intothe duodenum using an 11.5 mm occlusion balloon. Success rate, reason for fail-ure, and complications associated with the procedure were evaluated.

Results: Eight patients had one stone, five patients had two stones, and twopatients had more than five stones. The procedure was successful in 13 patients(13/15). In 12 of the patients, all stones were removed in the first trial. In onepatient, residual stones were discovered on follow-up cholangiography, and weresubsequently removed in the second trial. Technical failure occurred in twopatients. Both of these patients had severely dilated CBD and multiple stoneswith various sizes. Ten patients complained of pain in the right upper quadrantand epigastrium of the abdomen immediately following the procedure, but therewere no significant procedure-related complications such as bleeding or pancre-atitis.

Conclusion: Percutaneous extrahepatic biliary stone removal by balloonsphincteroplasty and subsequent stone pushing with occlusion balloon is aneffective, safe, and technically feasible procedure which can be used as an alter-native method in patients when endoscopic extrahepatic biliary stone removalwas not successful.

ile duct stones may be related to various clinical manifestations such asbiliary colic, obstructive jaundice, cholangitis, and biliary sepsis.Medication is needed to relieve clinical symptoms and improve patients’

clinical condition, although stone removal is necessary to completely remedy thecondition. Various methods including surgical and non-surgical techniques have beenused to remove bile duct stones. Among them, endoscopic sphincterotomy has beenrecognized as the primary modality to remove extrahepatic duct stones based on itseffectiveness and overall comfort of the patients. Its usefulness has been confirmed innumerous studies (1, 2), and it is being adopted as the main modality in most centers.

Development of devices and techniques used in endoscopic sphincterotomy hasimproved the success rate of stone removal. However, the use endoscopic sphinctero-tomy may be difficult or impossible in some clinical situations, including previous

Yong Sung Park, MD1

Ji Hyung Kim, MD1

Young Woo Choi, MD2

Tae Hee Lee, MD2

Cheol Mog Hwang, MD1

Young Jun Cho, MD1

Keum Won Kim, MD1

Index terms:Extrahepatic bile duct, calculiExtrahepatic bile duct, stone

extraction

Korean J Radiol 2005;6:235-240Received June 13, 2005; accepted after revision August 1, 2005.

Departments of 1Diagnostic Radiology and2Gastroenterology, Konyang UniversityHospital

Address reprint requests to:Yong Sung Park, MD, Department ofDiagnostic Radiology, Konyang UniversityHospital, 685 Gasoowon-dong, Seo-gu,Daejeon 302-718, Korea.Tel. (8242) 600-9195Fax. (8242) 600-9193e-mail: mdazzi70@yahoo.co.kr

B

operation of upper gastrointestinal (GI) tract, patients’intolerance or phobia for endoscopy, and anomaly of GItract among others, which require alternative therapeuticmodalities. As a surgical modality, peritoneoscopic biliarysurgery has been widely used. It is very effective andrelatively safe compared with conventional open surgery.However, general anesthesia is necessary to perform thesurgery and the cost of the procedure is high. Anotheralternative, transhepatic stone removal using a Dormiabasket has also been used. It is has been shown to behelpful, but a 12 to 16 F large diameter tract through theliver parenchyma is needed, and should be reserved untilthe tract is completely matured.

Gil et al. reported the effectiveness of balloon dilatationof the papilla and clearing CBD stones using occlusionballoon pushing (1). The study emphasized the procedurewas safe as well as simple, and it could be used as analternative to endoscopic sphincterotomy. Despite arelatively large number of patients in the study, indicationof the procedure was not definitely described in the report.It seems that competition with endoscophic sphicterotomyis time-consuming and not reasonable. We believe thetechnique outlined by Gil is valuable in patients whocannot undergo endoscopic sphincterotomy.

In this study, we present our experience for applyingballoon sphincteroplasty and occlusion balloon pushing toremove extrahepatic bile duct stones in patients whorefused endoscopic sphicterotomy or when endoscopicsphicterotomy was not successful, and discuss its technicalfeasibility and usefulness.

MATERIALS AND METHODS

From 2002 to 2004, fifteen patients (10 male, 5 female,54 89 years old, mean age: 69 years) who had refusedendoscopic sphicterotomy or when endoscopic sphictero-tomy was not successful, were referred from endoscopists.There were several reasons the endoscopic sphicterotomywas not successful. In six patients it was due to anatomicalchange caused by a previous operation, poor compliance inthree patients, intolerance due to poor general condition infour patients, and two patients refused the procedure dueto endoscopy phobia. All of the patients received prophy-lactic broad-spectrum antibiotics upon arrival at thehospital and following the procedure to prevent andmanage cholangitis.

At first, PTBD was performed in all patients to relieveclinical symptoms and ensure hepatic tract for theprocedure. For the convenience of the procedure, segment6 intrahepatic duct (IHD) was primarily punctured inPTBD. However, the segment 3 duct in the left lobe was

punctured in three patients with a normal diameter IHD insegment 6.

The procedure was performed 3 4 days after PTBD toensure at least minimal tract maturation and subsidence ofthe present cholangitis. Prior to the procedure, cholangiog-raphy with diluted contrast material was performed todefine the anatomy of the biliary tree and number, size,and location of the stones. Various analgesics wereadministered depending on the needs of each individualpatient. The procedure started by exchanging the catheterover a 150 cm, 0.035 inch diameter guide wire (RadifocusGuide wire M; Terumo, Tokyo, Japan) with the tip locatedin the duodenum. Next, 8 9 French vascular introducersheath (Radifocus; Terumo, Tokyo, Japan) with their distaltips were inserted in to the biliary tree. A 65 cm 5 F angledtaper angiographic catheter (Radifocus Glidecath; Terumo,Tokyo, Japan) was introduced through the introducersheath. Stiff type 0.035 inch guidewire with 260 cm oflength (Radifocus Guide wire M; Terumo, Tokyo, Japan)was passed through the angiographic catheter and thecatheter was then pulled out. A dilatation balloon catheter(Ultra-Thin Diamond; Boston Scientific, Medi-Tech, MA)was inserted over the stiff type guidewire and positionedacross the papilla. The balloon was then inflated withdiluted contrast material until the waist by papillarysphincter disappeared. Inflation was maintained for 30 60sec and repeated two or three times in each patient. Thediameter of the balloon ranged from 8 mm to 14 mm. Thesize of the dilatation balloon was determined by estimatingthe size of the largest extrahepatic bile duct stone, and didnot exceed 14 mm in order to avoid possible rupture of thecommon bile duct.

After dilation, the balloon was carefully removed toavoid pulling the stones proximally into the intrahepatictree, and exchanged for an 11.5 mm standard occlusionballoon catheter (Standard Occlusion Balloon Catheter;Boston Scientific, Medi-Tech, MA). The balloon wasinflated with diluted contrast material proximal to thestones and advanced over the guidewire through thepapilla and into the duodenum. This maneuver wasrepeated until the stone was evacuated completely fromthe extrahepatic bile duct. By controlling the volume of theballoon with the syringe, it was possible to modulate itssize in the duct. If the patient suffered from pain during theprocedure, it was helpful to administer about 10 cc of 2%lidocaine into the bile duct via the introducer sheath.

The evacuation of the bile duct stone was confirmed byobserving filling defects in the contrast agent-filledduodenum. The procedures described above are illustratedin Fig. 1. The balloon and the introducer were thenremoved, and a 10 F drainage catheter was placed in the

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236 Korean J Radiol 6(4), December 2005

common bile duct. This catheter remained in place for 3 7days to allow external drainage. Pancreatic enzyme studywas performed routinely to evaluate the onset of acutepancreatitis. Before removing this catheter, cholangiogra-phy was obtained to determine if the biliary tree was freeof stones and easy flow of contrast material into theduodenum was shown. We evaluated the success rate,

reason for failure, and complications associated with theprocedure.

RESULTS

Eight patients had one stone, five patients had twostones, and two patients had more than five stones. The

Extrahepatic Biliary Stone Removal Using Balloon Sphincteroplasty and Occlusion Balloon Pushing

Korean J Radiol 6(4), December 2005 237

A B C

D FE

Fig. 1. Fourty-three year-old female patient with a common bile duct stone and relatedright upper quadrant pain. This patient refused endoscopy, due to a terrible experienceduring a previous endoscopy (A) percutaneous transhepatic biliary drainage is performed,showing a stone in the common bile duct.B. The stone is pushed more distally using a 5 F catheter, and 0.035 inch stiff wire ispassed to the duodenum.C. Using a 10 mm dilatation balloon, the ampullary sphincter is dilated.D. 11.5 mm occlusion balloon (white arrow) is inserted into the common bile duct, justproximal to the stone (black arrow).E. Using the occlusion balloon, the stone is pushed into the duodenum.F. The stone is completely pushed into the duodenum.G. The stone is shown in the duodenum (arrow).

G

procedure was successful in 13 patients (13/15). The size ofthe CBD in these patients was less than 15 mm and thesize of the stones were 5 10 mm. In 12 patients, all stoneswere removed in the first trial. In one of the patients withone extrahepatic bile duct stone, another stone was notobserved on cholangiography which was performed priorto and immediately after the the procedure. The hiddenstone was completely removed in the second trial.Technical failure occurred in two patients. Both of themhad severely dilated CBD measuring over 15 mm andmultiple stones with the largest stone measuring less than10 mm (Fig. 2). In two patients, additional stones otherthan the extrahepatic bile duct stones were located in thecystic duct and primary intrahepatic duct, which werepulled down to the extrahepatic bile duct using angletapered angiographic catheter.

All patients complained of sharp pain in the right upper

abdomen during balloon dilatation of the sphincter.However, it subsided relatively quickly following balloondecompression. Ten patients complained of mild tomoderate dull pain in the right upper abdomen followingthe procedure. This pain was controlled with analgesicagents and subsided within one or two days. There wereno significant procedure-related complications such asbleeding, perforation or acute pancreatitis.

DISCUSSION

Endoscopic sphincterotomy has become the first line oftreatment for patients with extrahepatic bile duct stones.However, this technique may not be successful due todifficult anatomy, previous surgery, periampullarydiverticula, the presence of a large stone (3), or thistechnique may not be performed due to refusal by patients

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238 Korean J Radiol 6(4), December 2005

A B C

D FEFig. 2. Fifty-six year-old male complaining of fever and right upper quadrant pain.A. Multiple filling defects are seen in Common bile duct, indicating multiple stones. Common bile duct is severely dilated, measuring 16-17 mm in diameter.B-D. Stone evacuation with occlusion balloon failed. The occlusion balloon passed over the stone, unable to push the stones effectively.E. Even a larger sized balloon (13 mm), that is used for endoscopic common bile duct stone removal, fails in pushing the stones.F. Multiple stones still remain in common bile duct.

with endoscopy phobia. A comparison of endoscopicsphincterotomy and balloon sphincteroplasty has beenreported in previous studies (4, 5). These studies indicatedthat endoscopic sphincterotomy was superior toendoscopic papillary balloon dilation based on stoneremoval, duration of the procedure, and complicationrates. On the other hand, some studies have mentioned theadvantages of percutaneous or endoscopic balloon sphinc-terotomy (2, 6, 7). These studies noted endoscopic balloonsphincterotomy was very safe, effective, and advantageousfor the preservation of the papillary function. Generally,endoscopists believe that there is a higher risk for acutepancreatitis associated with balloon sphinteroplasty thanendoscopic sphincterotomy. However, according to theresults of the study by Gil et al. (1), acute pancreatitis wasextremely rare, which is consistent with the results fromthis study. We did not experience any serious complica-tions such as acute pancreatitis, hemobilia, or infection.Patients only complained of discomfort during the sphinc-teroplasty and following the procedure. However, it waswell controlled by 2% lidocaine infusion into the bile ductand analgesics medications with non-steroid antiinflamma-tory drugs. No patient complained of pain for more thantwo days.

The technique described in this study also hasadvantages over percutenous extrahepatic biliary stoneremoval technique using a Dormia basket. As Burhenne etal. reported, Dormia baskets have high success rates andlow complication rates (8). The success rate has beenshown to be 95%, and complication rates have beenreported to be around 4% (8 11). However, the Dormiabasket method requires a larger tract diameter, and itshould be reserved for at least 4 6 weeks for maturationof the transhepatic tract (8, 9, 12 15). Our techniquerequires only 3 4 days after PTBD, which can reducehospitalization period. For the tract diameter, ourtechnique needed only an 8 9 F sheath passing to performthe procedure.

In the present study the success rate in initial trial wasvery high. Only one patient underwent two sessions of theprocedure to eliminate all the extrahepatic bile duct stones.Technical failure occurred in two patients due to multiplestones and severely dilated common bile duct measuringapproximately 15 mm. An 11.5 mm occlusion ballooncould not fully cover the diameter of the dilated commonbile duct to push the stones and it slipped over the stoneswithout effective stone pushing. We repeatedly triedpushing the stones with a larger 13 mm balloon used inendoscopic extraction of CBD stones, although it was stillnot successful after more than ten attempts during the trial.

A limitation of this study was that all the subjects had

extrahepatic biliary stones measuring less than 10 mm.Consequently, the successful results demonstrated in thisstudy may not always be duplicated, especially in patientswith larger extrahepatic biliary stones. We only used11.5 13 mm occlusion balloons for stone extractionbecause we dilated the papilla with dilatation balloon from8 mm to 14 mm. We did not attempt stone extraction withlarger sized occlusion balloons in the two patients withextremely dilated common bile ducts, and in which theprocedure was not successful that reason. A more aggres-sive approach may have lead to successful stone extractionin these cases.

Even though endoscopic sphincterotomy is preferred inextrahepatic duct stone removal in most centers, alterna-tive methods are necessary in various clinical situations.The results of this study show that balloon sphincteroplastywith occlusion balloon pushing is a very safe and effectivetreatment modality to remove extrahepatic duct stones,and it can be used in patients with anatomical or clinicaldifficulties for endoscopic sphincterotomy as an excellentalternative modality.

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